DESCRIPTION (APPLICATION ABSTRACT): Health care quality has recently received significant attention, primarily due to the issue of medical errors. We propose an innovative study to a) characterize a multifactoral web of factors that have an impact on health care quality (both patient safety and satisfaction) and b) focus on a relatively underexamined causal route to quality: working conditions and resultant employee health, fatigue, and satisfaction. The primary research goals are: 1) To identify a spectrum of root organizational factors that affect the quality of patient care and safety, with primary emphasis on the determinants of working conditions relevant to these outcomes. 2) To identify the pathways through which these working conditions affect the quality of patient care. 3) To characterize the role of employee health (mental and physical), fatigue, and job satisfaction in linking working conditions to quality of patient care. 4) To identify intervention points and develop practical intervention strategies for improving the quality of care. Using instruments from previous research for the Veterans Administration, the study will focus on quality of care and patient safety in community-based health clinics (CHCs). Study sites (approximately 12) consist of three samples: a) VA CBOCs (community based outreach centers), b) urban CHCs from Boston HealthNet, and c) more rural CHCs from the CT AHEC. Approximately 2,000 employees, at different levels in the organizations, will be given questionnaires. Items will include management and employee perceptions of organizational characteristics, working conditions (physical and psychosocial risks), employee health, and patient care quality. Patient satisfaction questionnaires will be given to samples of the client populations. Record-derived data will include employee lost time and sick time and measures of patient care quality and satisfaction. Expert observers will also characterize physical and psychosocial working conditions. Longitudinal data, collected at three points over two years, will strengthen hypotheses of causal direction. Findings will be compared to previous research with VA national data. A dual strategy of preliminary structural equation modeling, followed by regression and hierarchical regression modeling, will be used to identify the multiple pathways linking organizational characteristics, working conditions, employee health, and quality of patient care and safety. The study will use results to develop site-specific intervention strategies and to disseminate this information to a wider audience.